Sunday, January 06, 2008

Our "Falling Down" Profession

It’s so nice to be classified (with lawyers) by the New York Times as a “Falling Down” profession. I love sitting and feeling sorry for myself. Poor me.

Caveat emptor when we look to the journalism field to provide cultural direction versus spin. The spin of this article (or Achilles heel) is that the author, like the breathless digital economy "pile-on"-ers, exists as if the picture he paints can in fact be the truth. The sad thing, as Silicon Valley found out in round one, is that the digital star factory does not float all ships (nor does the financial industry or banking industry) as “stars” with short attention spans and wishes for a quick million find, as they sit in their mother’s basement playing their twentieth round of Call of Duty 4, waiting for Microsoft to call. This is not reality, but perhaps the dream is more important.

Further, unlike many of us, the author has clearly not confronted his own reality – which in more philosophical circles might be referred to as his personal mortality. Nor, perhaps, has he confronted it in the dark deserted hallways of a medical center with a family member or best friend. Doctors fail to have the luxury of this protected viewpoint.

No matter.

The spin that enchants now will matter less when the digital inamoratas are pressing the nurse call button for the tenth time at 3 AM in the morning. The belief in a new gold rush is uniquely American, and one would have to be deaf dumb and blind to miss the twin engines of the digital economy and globalization. But there is another force out there – the aging of the populace and the growing expectations for personal health, longevity and attentive care. When the first diagnosis hits, the Blackberry goes silent. The charm of instant lottery-style winnings, or at least our belief in them, fades as one searches for at least one honest trustworthy face to gaze into as one wrestles with his own diagnosis. This is not negativity, this is reality. We live in fungible biological assets no matter which home healthcare program tracks our personal “wellness.” Perhaps the “falling down” status of medical professionals represents a type of killing the messenger.

Better solutions will need to be found to support, reward, and encourage a top quality front-line of care for the day you become ill. Or the day the EA Games or Time Warner executive becomes ill. It’s that simple. To believe otherwise is naïve and wishful. We remain immersed in our own denial until our personal chronological buzzer goes off, rather than insisting that the personal, hand-holding, high quality healthcare we hope for will be there in the future. The American belief in the new, the shiny, the whiz-bang gizmos – these are all amusing unless they leave us unprepared later in life. The emphasis on entertainment and distraction, quick riches, and risky ventures is the stuff of the young and the lucky, it is not the stuff of your average Joe. We elevate these players at great expense to our culture. We elevate them oblivious to the expense to the teachers, nurses, scientists, doctors and other careful plodders who make up the real gold of this world.

Don’t get me wrong, there are disappointing things happening in medicine these days. Even doctors are not immune to corporate seduction with our consulting arrangements, speakers’ fees, kickbacks, drug lunches and royalty payments. But these doctors with journalists, policy wonks, corporate executives, marketing agents, and the financial engines that comprise the business of medicine, are beginning to undergo scrutiny. For the first time with the help of the information age, patients understand how each of these entities serves their own economic interest before the patient. Skim the profits, make more money, grow, baby, grow – even if it means changing the front-line care of the very patients they claim to serve.

But patients are starting to understand that healthcare is a zero-sum game – the money that funds spas and new hospital construction or equipment purchases (to stay “competitive”) comes out of somewhere. The money that funds error control and quality assurance – and the entire new layer of executives funded by these efforts – comes out of somewhere. The money for acquiring and selling electronic patient data and direct-to-patient marketing campaigns comes out of somewhere. Patients must insist it does not come out of their front-line care, or their costs at the Walgreen’s counter.

So while I understand the author's misguided attempt to label, I'd suggest the next time he's sick, he reconsider his spin. Medicine touches the core of human existence, from the moments of pregnancy and birth to the last breaths of life here on earth. It deals daily with individuals and families with all of their complicated dynamics and concerns with illness, suffering, pain, and the challenges that go along with these. Most of all, it deals in reality, not spin: those unwavering and inevitable medical crises that each of us will confront eventually. Fortunately, a few of our politicians are beginning to realize this. They realize that doctors have direct (and priveledged) access to the one asset that every political campaign envies: their constituents. For if the politicians and policy pundits think we’ll be crying “poor me” as they cut physicians’ reimbursements further, just wait until their constituency raises hell when they can't find a capable doctor or nurse.

3 comments:

I like your overall take on the article, but wonder where you got the thought that healthcare is a zero sum game.

It certainly hasn't been flat for a long time-- overall economic growth rates have been 2-3X over inflation for a long time.

With the demographic shift caused by boomer retirement, decreasing immigration, and declining birth rate, one would expect that care needs would intensify. A growing awareness of need for prevention/ wellness is likely to increase health spend in the short term on these measures.

So while infighting between different industries always happens, it would seem that nobody's really doing badly-- big pharma's at the end of a cycle, but that has to do more with a dearth of innovation in new classes than anything else.

I am not confusing the growth of our economy (vs. inflation) with the growth in the cost of healthcare. Certainly, many have benefitted from the rosey economy. After all, healthcare supports about 16% of our GNP presently, and is projected, at our current growth rate, to expand to 25% of our GNP by 2025 (data from the Congressional budget Office). But who's paying the tab for healthcare? Employers (who increase their costs of their goods to cover the expense), patients, or the government (also known as the patients en masse). I would argue the patients pay ultimately. After all, they're the ones paying more, having more procedures covertly rationed, seeing exorbitant upcharging by hospitals who cover their expenses for spas and waterfalls and Starbucks in their hospital lobbies. The Little Man pays, while the Big Man runs off with options worth hundreds of millions of dollars (you know of whom I speak). In the end, the every day Joe is losing in our current system while the corporate interests profit - hence the concept of zero sum for the average patient.

It's always interesting to me to hear the oft-uttered "You won't be able to find a doctor" argument. Where will you all go? Will you become bankers? Venture capitalists? You speak of reality, but the reality is that when government health reform is implemented (in whatever form it takes), you will not change careers and you will accept what is handed to you, because you will have to in order to remain in business. You can tell yourself that you can just open a concierge practice and only accept well-off patients who can pay your entire fee out-of-pocket plus an annual retainer, but good luck running an entire practice with that business model. Doctors, as a group, have always been extremely good at making lots of noise and tossing around empty threats, but a majority of you would go out of business if you stopped accepting Medicare. On average, Medicare makes up 25% of the revenue of the average medical practice. The same thing will be true with the outcome of reform. You need patients to stay in business. THAT is the reality. Sorry. You just don't have the total control that you think you have. And the system/world just doesn't revolve around you like you think it does. THAT is the reality. While the squeaky wheel often gets the grease, the squeaky wheel of organized medicine has, over the years, become an irritating mosquito buzzing around the ears of a public that grows increasingly numb to the sound and less and less concerned about the potential bite.

About Me

Westby G. Fisher, MD, FACC is a board certified internist, cardiologist, and cardiac electrophysiologist (doctor specializing in heart rhythm disorders) practicing at NorthShore University HealthSystem in Evanston, IL, USA and is a Clinical Associate Professor of Medicine at University of Chicago's Pritzker School of Medicine. He entered the blog-o-sphere in November, 2005.
DISCLAIMER: The opinions expressed in this blog are strictly the those of the author(s) and should not be construed as the opinion(s) or policy(ies) of NorthShore University HealthSystem, nor recommendations for your care or anyone else's. Please seek professional guidance instead.